attached A3230-01 INITIAL 8. COSTS REQUESTED FOR PROPOSED PERIOD OF SUPPORT 7b. Total Coots ($) 8a. Direct Costs ($) 8b. Total Costs ($) 330,842 1,577,385 1,681,025 10. TYPE OF ORGANIZATION Public: --_ [] Federal [] State [] Local Private: -.-) [] Private Nonprofit For-profit: _ [] General [] Small Business [] Woman-owned [] Socially and Economically Disadvantaged 11. ENTITY IDENTIFICATION NUMBER 060646973 DUNS NO. (if available) 04-320-7562 Congressional District 3 13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION Name Verna M. Lingis/Rebecca Balentine Title Assoc. Dir/Asst. Dir, Grant&Contract Admin Address Yale University School of Medicine 47 College St, Suite 203-P.O.Box 208047 NAw H_vAn P,,T t3RRPO-R047 Telephone 203-785-4689 FAX 203-785-4159 E-Mail grantsmd @_ail,med.yale.edu DATE SIGNA_URE-)Of PI_N_IED IN aM. SIGNATURE OF OFFICIAL NAMED IN 13. DATE (/n ink. "Per" signature not acceptable.) a"_ / _ __t''f _ P Form Page I + +